Treatment of HIV and acute myeloid leukemia by allogeneic CCR5-d32 blood stem cell transplantation Elena Knops Elena Knops, AREVIR, Cologne 2017
Background - the Berlin patient – so far the only person presumed to be cured from HIV by hematopoietic stem cell transplantation (HSCT) from a homozygous CCR5-d32 donor Elena Knops, AREVIR, Cologne 2017
Background - the Berlin patient – so far the only person presumed to be cured from HIV by hematopoietic stem cell transplantation (HSCT) from a homozygous CCR5-d32 donor - failed attempts to reproduce cure by HSCT - viral rebound or death due to underlying malignancy Elena Knops, AREVIR, Cologne 2017
The whole story (drama in 5 acts) 48y old patient, alive, well and undetectable for HIV (RNA/DNA) over 4 years after allogeneic CCR5-d32 HSCT Elena Knops, AREVIR, Cologne 2017
The beginning (prologue) induction consolidation Elena Knops, AREVIR, Cologne 2017
The beginning (prologue) induction consolidation AML diagnosis in Jan 2011 Elena Knops, AREVIR, Cologne 2017
The beginning (prologue) complete remission of AML induction consolidation Elena Knops, AREVIR, Cologne 2017
The beginning (prologue) induction consolidation to avoid interactions with chemotherapy TDF/FTC/RAL Elena Knops, AREVIR, Cologne 2017
Chapter I September 2012 female donor, 10 out of 10 HLA- 2 cycles high-dose cytarabine matched CCR5-d32 .... .... one week before SCT Elena Knops, AREVIR, Cologne 2017
Chapter I stem cells from female, 10/10 HLA-matched CCR5-d32 donor .... .... one week before SCT Elena Knops, AREVIR, Cologne 2017
Chapter I .... .... one week before SCT Elena Knops, AREVIR, Cologne 2017
Chapter I .... .... one week before SCT Elena Knops, AREVIR, Cologne 2017
Chapter II during transplant and until today on ART .... Elena Knops, AREVIR, Cologne 2017
Chapter II June 2013 total of 8 courses of 5-azacytidine + 4 donor lymphocyte infusions .... Elena Knops, AREVIR, Cologne 2017
Chapter III + CMV, HHV8, HSV 10 10 10 0 0 0 .... ................ ................ 2017 <LOD (884250) in rectal and ileum biopsy Elena Knops, AREVIR, Cologne 2017
Chapter III + CMV, HHV8, HSV + increased liver values 10 10 10 0 0 0 .... ................ 2017 <LOD (884250) in rectal and ileum biopsy Elena Knops, AREVIR, Cologne 2017
Chapter III + CMV, HHV8, HSV Tacrolimus + topical steroids 10 10 10 0 0 0 .... ................ 2017 <LOD (884250) in rectal and ileum biopsy Elena Knops, AREVIR, Cologne 2017
Chapter III + CMV, HHV8, HSV Tacrolimus + topical steroids .... ................ 2017 <LOD (884250) in rectal and ileum biopsy Elena Knops, AREVIR, Cologne 2017
Chapter III + CMV, HHV8, HSV Tacrolimus + topical steroids .... <LOD (884250) in rectal and ileum biopsy Elena Knops, AREVIR, Cologne 2017
Chapter III + CMV, HHV8, HSV Tacrolimus + topical steroids .... - PBMCs - rectal + ileum - bone marrow - CSF Elena Knops, AREVIR, Cologne 2017
Chapter III Tacrolimus + topical steroids ABC/3TC/DTG <20 <20 505 318 .... 2016 2017 <LOD <LOQ <LOQ <LOQ <LOQ (884250) (10 Mio) (10 Mio) (3,8 Mio) (15 Mio) in rectal and 1/20 repl 1/10 repl ileum biopsy 52 month after SCT Elena Knops, AREVIR, Cologne 2017
Chapter V month 39 40 41 42 after SCT 2016 Mar Apr May Jun ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddPCR or qPCR, but positive signals in T-cell subsets: T CM : 0.2 Mio cells (ddPCR) – 6.7cop/10 6 cells T EM : 0.36 Mio cells (qPCR) – 5 cop/10 6 cells Elena Knops, AREVIR, Cologne 2017
Chapter V month 39 40 41 42 after SCT 2016 Mar Apr May Jun ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddPCR or qPCR, but positive signals in T-cell subsets: T CM : 0.2 Mio cells (ddPCR) – 6.7cop/10 6 cells T EM : 0.36 Mio cells (qPCR) – 5 cop/10 6 cells G. Dunay, Hamburg: Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers Elena Knops, AREVIR, Cologne 2017
Chapter V month 39 40 41 42 after SCT 2016 Mar Apr May Jun ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddPCR or qPCR, but positive signals in T-cell subsets: T CM : 0.2 Mio cells (ddPCR) – 6.7cop/10 6 cells T EM : 0.36 Mio cells (qPCR) – 5 cop/10 6 cells G. Dunay, Hamburg: Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers ICISTEM (J. Martinez-Picado & M. Salgado, Barcelona): qVOA: 23 Mio CD4 + T cells negative (IUPM < 0.031/10 6 CD4 T cells) 0.007 Mio CD45+ cells negative (<143/10 6 CD45+ cells) Ileum biopsy: 0.0297 Mio CD45+ cells negative (<34/10 6 CD45+ cells) Rectum biopsy: Elena Knops, AREVIR, Cologne 2017
Chapter V month 39 40 41 42 after SCT 2016 Mar Apr May Jun ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddPCR or qPCR, but positive signals in T-cell subsets: T CM : 0.2 Mio cells (ddPCR) – 6.7cop/10 6 cells T EM : 0.36 Mio cells (qPCR) – 5 cop/10 6 cells G. Dunay, Hamburg: Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers ICISTEM (J. Martinez-Picado & M. Salgado, Barcelona): qVOA: 23 Mio CD4 + T cells negative (IUPM < 0.031/10 6 CD4 T cells) 0.007 Mio CD45+ cells negative (<143/10 6 CD45+ cells) Ileum biopsy: 0.0297 Mio CD45+ cells negative (<34/10 6 CD45+ cells) Rectum biopsy: I. Hauber, Hamburg: mVOA: negative in plasma, negative in histology Elena Knops, AREVIR, Cologne 2017
Chapter V Rag#1DD hu-CD3 HIVp24Ag Spleen Liver LN I. Hauber, Hamburg: mVOA: negative in plasma, negative in histology Elena Knops, AREVIR, Cologne 2017
Chapter V P HENOTYPIC C O - RECEPTOR T ROPISM A NALYSIS (sample before transplantation, PBMC) # sequencing genotypic prediction phenotypic analysis in Tcells FPR (%) Magi (R5/X4) MT2 (X4) Clone gp120-V3 amino acid sequence reads D1 CTRPNNNTREGIHIGPGRAFFTTGEIIGNIREASC 4 95,78 R5 R5 D2 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIKEAYC 2 95,64 R5 R5 D3 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIGEAYC 2 95,64 R5 R5 D4 CTRPNNNTRKGIHIGPGRAFFTTGEIIGNIREASC 2062 77,33 R5 R5 D5 CTRPNNNTRKGITIGPGRAFFTTGEIIGDIRQAHC 4886 30,67 R5 R5 D6 R5/X4 CTRPNNNTRKGIHIGSRKAFFTTGGIIGDIRQAYC 2 10,61 X4 D7 R5/X4 CTRPHTNTRKRIHIGPGRAFFTTGEIIGDIRQAYC 7 1,74 X4 D8 CTKPNNNTRKRIHIGPGRAFFTTGEIIGNIRQASC 2 1,74 R5 R5 D9 R5/X4 CTRPNNNIRKRIHIGPGRAFFTTGEIIGNIREAYC 3 1,16 X4 HxB2V3Bal control R5 51,8 R5 R5 HxB2 control X4 0 X4 X4 Monique Nijhuis, Utrecht, ICISTEM Elena Knops, AREVIR, Cologne 2017
Chapter V C O - RECEPTOR TROPISM (sample before transplantation, PBMC) # sequencing genotypic prediction phenotypic analysis in Tcells FPR (%) Magi (R5/X4) MT2 (X4) Clone gp120-V3 amino acid sequence reads D1 CTRPNNNTREGIHIGPGRAFFTTGEIIGNIREASC 4 95,78 R5 R5 D2 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIKEAYC 2 95,64 R5 R5 D3 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIGEAYC 2 95,64 R5 R5 D4 CTRPNNNTRKGIHIGPGRAFFTTGEIIGNIREASC 2062 77,33 R5 R5 D5 CTRPNNNTRKGITIGPGRAFFTTGEIIGDIRQAHC 4886 30,67 R5 R5 D6 R5/X4 CTRPNNNTRKGIHIGSRKAFFTTGGIIGDIRQAYC 2 10,61 X4 D7 R5/X4 CTRPHTNTRKRIHIGPGRAFFTTGEIIGDIRQAYC 7 1,74 X4 D8 CTKPNNNTRKRIHIGPGRAFFTTGEIIGNIRQASC 2 1,74 R5 R5 D9 R5/X4 CTRPNNNIRKRIHIGPGRAFFTTGEIIGNIREAYC 3 1,16 X4 HxB2V3Bal control R5 51,8 R5 R5 HxB2 control X4 0 X4 X4 Monique Nijhuis, Utrecht, ICISTEM Elena Knops, AREVIR, Cologne 2017
The end? (epilogue) More assays to be done: - qVOA + ultra microchimerism (ICISTEM: M. Salgado, Barcelona): lymph node (planned) - T-cell response assay (T. Harrer, Erlangen): PBMCs from donor (in progress) - proviral DNA load from further PBMC samples and lymph node (Institute of Virology, Cologne and others) - … International collaboration to guide and investigate the potential for HIV cure by stem cell transplantation. The ICISTEM project is supported by amfAR Research Consortium on HIV eradication (ARCHE) Research Grant # 108930-56-RGRL www.icistem.org Elena Knops, AREVIR, Cologne 2017
Thanks to our group University of Düsseldorf Institute of Virology, University of Cologne Hepatology & Infectiology Rolf Kaiser Björn Jensen Eva Heger Falk Hüttig Veronica Di Cristanziano Dieter Häussinger Maria Neumann-Fraune Eugen Schülter Virology Claudia Müller Nadine Lübke Saleta Sierra-Aragon Sascha Hasheminasab Haematology Guido Kobbe Moleculare Medizin Philipp Lang Junnat Hamdam Institute for Immunogenetics, Kaiserslautern Martin Däumer, Alex Thielen Heinrich Pette Institut HH Ilona Hauber, Gabor Dunay, Johanna Eberhard, Silke Kummer, Julian Schulze zur Wiesch Med 3, University of Erlangen Thomas Harrer IciStem project Annemarie Wensing, Javier Martinez-Picado, Monique Nijhuis et al. MPI of Informatics, Saarbrücken Thomas Lengauer, Joachim Büch, Nico Pfeifer, Alejandro Pironti, Prabhav Kalaghatgi Elena Knops, AREVIR, Cologne 2017
Thanks to the „Duesseldorf“ patient Elena Knops, AREVIR, Cologne 2017
Intermezzo gp160 gp120 gp41 p68 p55 p34 p25 p18 pos. control neg. control 02/2013 before SCT 06/2014 02/2015 07/2015 12/2015 01/2016 Elena Knops, AREVIR, Cologne 2017
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